NCCN Guidelines® Insights: Myelodysplastic Syndromes, Version 3.2022

The NCCN Guidelines for Myelodysplastic Syndromes (MDS) provide recommendations for the evaluation, diagnosis, and management of patients with MDS based on a review of clinical evidence that has led to important advances in treatment or has yielded new information on biologic factors that may have prognostic significance in MDS. The multidisciplinary panel of MDS experts meets on an annual basis to update the recommendations. These NCCN Guidelines Insights focus on some of the updates for the 2022 version of the NCCN Guidelines, which include treatment recommendations both for lower-risk and higher-risk MDS, emerging therapies, supportive care recommendations, and genetic familial high-risk assessment for hereditary myeloid malignancy predisposition syndromes.

Acute promyelocytic leukemia during pregnancy: A case report and 10-year institutional review of hematologic malignancies during pregnancy

Acute promyelocytic leukemia (APL) manifesting during pregnancy is a very rare but highly challenging gestational complication in part due to its associated profound coagulopathy. We present the case of a 23-year-old Gravida 3 Para 2002 woman admitted to our hospital at 26 weeks of gestation for severe pre-eclampsia with documentation of intrauterine fetal demise (IUFD), thrombocytopenia, and placental abruption. A peripheral blood smear revealed promyelocytes with azure granules, highly concerning for APL. Additional peripheral blood studies confirmed APL. Placental examination also revealed circulating blasts in decidual vessels and scattered blast entrapment in diffuse perivillous fibrinoid deposits, but none in the chorionic villi. Treatment for APL was initiated immediately and she is in complete molecular remission. Our case underscores the importance of close collaboration among obstetric, hematology, and pathology teams in the care of patients with pre-eclampsia, thrombocytopenia, and postpartum coagulopathy. We also describe five additional cases of gestations complicated by hematologic malignancies identified upon a 10-year institutional retrospective review.

Drug-induced acute liver failure in children and adults: Results of a single-centre study of 128 patients

BACKGROUND & AIMS

Drugs producing acute liver failure (ALF) are uncommon and vary geographically. Here we review the implicated drugs, clinical features, laboratory characteristics and outcome of patients with drug-induced ALF (DIALF). We analysed the predictors of mortality and their relationship with MELD, King's College criteria (KCC) and ALFSG prognostic index.

METHODS

We identified DIALF patients from our drug-induced liver injury (DILI) registry (1997-2017). RUCAM was used for case adjudication. Patients who fulfilled criteria for acute liver failure and drug-induced liver injury were included. Primary outcome measure was spontaneous survival or death.

RESULTS

There were 128 cases of DIALF (14%) among 905 patients with DILI. Mean age was 38 years, 68 (53%) female and 21(16.4%) children <18 years. Combination anti-TB drugs (ATD) (n = 92, 72.4%) accounted for a majority of DIALF. Others were anti-epileptic drugs (AED, n = 11, 10%), dapsone (n = 7, 5.5%), hormones (n = 2), ferrous sulphate overdose (n = 2), acetaminophen (APAP) (n = 2), antiretroviral (n = 2), CAM (N = 2), chemotherapy agents (N = 3), amoxicillin-clavulanic acid (n = 2) and others (n = 3). Forty-four patients (34%) recovered spontaneously and 84(66%) including 13 children (62%) died. Females, ascites, albumin, bilirubin, INR and MELD were significantly associated with mortality. Mortality was 79% for ATD and 100% for APAP and iron overdose. Area under ROC was 0.76 for MELD and ALFSG index and 0.51 for KCC.

CONCLUSIONS

Fourteen percent of DILI resulted in DIALF. ATD, AED, dapsone and antiretroviral drugs are most common agents. Spontaneous survival was only 34% with an even higher mortality with ATD. Non-ATD and non-APAP drugs had a better survival (51%).INR and MELD predicted mortality.

Proton magnetic resonance spectroscopy of brain in obstructive sleep apnoea in north Indian Asian subjects

BACKGROUND & OBJECTIVES

Repeated apnoeic/hypoapnoeic episodes during sleep may produce cerebral damage in patients with obstructive sleep apnoea (OSA). The aim of this study was to determine the absolute concentration of cerebral metabolites in apnoeic and non-apnoeic subjects from different regions of the brain to monitor the regional variation of cerebral metabolites.

METHODS

Absolute concentration of cerebral metabolites was determined by using early morning proton magnetic resonance spectroscopy ((1)H MRS) in 18 apnoeic patients with OSA (apnoeics) having apnoea/hypopnoea index (AHI) >5/h, while 32 were non-apnoeic subjects with AHI< 5/h.

RESULTS

The absolute concentration of tNAA [(N-acetylaspartate (NAA)+N-acetylaspartylglutamate (NAAG)] was observed to be statistically significantly lower (P<0.05) in apnoeics in the left temporal and left frontal gray regions compared to non-apnoeics. The Glx (glutamine, Gln + glutamate, Glu) resonance showed higher concentration (but not statistically significant) in the left temporal and left frontal regions of the brain in apnoeics compared to non-apnoeics. The absolute concentration of myo-inositol (mI) was significantly high (P<0.03) in apnoeics in the occipital region compared to non-apnoeics.

INTERPRETATION & CONCLUSIONS

Reduction in the absolute concentration of tNAA in apnoeics is suggestive of neuronal damage, probably caused by repeated apnoeic episodes in these patients. NAA showed negative correlation with AHI in the left frontal region, while Cho and mI were positively correlated in the occipital region and Glx showed positive correlation in the left temporal region of the brain. Overall, our results demonstrate that the variation in metabolites concentrations is not uniform across various regions of the brain studied in patients with OSA. Further studies with a large cohort of patients to substantiate these observations are required.

Neurolymphomatosis associated with muscle and cerebral involvement caused by natural killer cell lymphoma: a case report and review of literature

We report a biopsy-proven case of neurolymphomatosis (NL) presenting with sensory motor axonal polyneuropathy, polymyositis, and cerebral involvement. Ours is the second reported case of NL caused by natural killer-cell lymphoma defined by morphology and immunophenotyping. For 3 months, the patient developed stocking-glove distribution of hypesthesia, subacute progressive weakness and mental deterioration. EMG showed severe sensorimotor mixed axonal-demyelinating polyradiculoneuropathy. Lumbar puncture revealed mildly high protein level with normal glucose and cell count. Sural nerve biopsy demonstrated lymphomatous axonal neuropathy and muscle biopsy was indicative of lymphomatous polymyositis. Brain MRI revealed multiple white matter lesions, consistent either with progressive multifocal leukoencephalopathy or cerebral lymphoma. Bone marrow biopsy showed neoplastic infiltrates. The patient died of multiple organ failure prior to initiation of chemotherapy.

Use of the Internet in pathology resident training and education

The Internet has revolutionized the computer and communications world. It has grown to become a worldwide mechanism for information exchange without regard for geographic boundaries. The tremendous growth in this wealth of information poses several questions regarding the utility of this powerful tool in pathology practice and education. This article reviews the advantages and disadvantages of using the Internet in pathology resident education, in general, and how it has impacted the repertoire of educational opportunities at our own institution. The various Internet resources of educational value for pathology trainees are outlined. Basic Internet concepts are also elucidated.

Topics in bone marrow biopsy pathology: role of marrow topography in myelodysplastic syndromes and evaluation of post-treatment and post-bone marrow transplant biopsies

The role of bone marrow biopsy is expanding. Bone marrow biopsy is considered a "gold standard" for assessing cellularity and infiltrative process. More recently, biopsies are increasingly used for immunohistochemical stains and molecular studies such as in situ hybridization and laser microdissection, further augmenting morphologic interpretation. Biopsies are playing a greater role in early diagnosis of myelodysplastic syndromes (MDS). Both primary and secondary MDS are increasing (5% to 12%), and can present a significant challenge in early diagnosis. Present MDS diagnostic criteria are based purely on marrow aspirate smears, peripheral blood smears, and ancillary studies, and may not be adequate in some instances. With the current understanding of marrow topography and hematopoietic microenvironment, bone marrow biopsies are greatly useful in early diagnosis and grading of MDS. Marrow biopsies also are helpful in evaluation of postchemotherapy and post-bone marrow transplant patients. Assessment of topographic alteration and certain corroborating immunohistochemical and molecular studies can only be performed on bone marrow biopsies, and these ancillary studies will contribute significantly to the understanding of hematopoietic disorders. Bone marrow biopsy, in conjunction with other modalities such as flow cytometry, will play a significant role in diagnostic hematopathology. Ann Diagn Pathol 5:110-120, 2001.

Transesophageal echocardiographic findings of an intracavitary cardiac metastasis from a neuroendocrine thymic carcinoma

This case report presents the unusual characteristics of a neuroendocrine thymic carcinoma that probably has metastasized to the left side of the interatrial septum from a primary thymic site.

Molariform supernumerary tooth--a case report

The occurrence of a single supernumerary tooth in the upper canine region a rare condition is reported. The crown resembles a molar tooth, thus suggesting a molariform supernumerary tooth.

Histologic examination of bone marrow core biopsy specimens has limited value in the diagnosis of mycobacterial and fungal infections in patients with the acquired immunodeficiency syndrome

Bone marrow cultures and biopsy specimens are commonly obtained to rule out disseminated infections, especially in persons with the acquired immunodeficiency syndrome (AIDS) and cytopenias. Using culture as the gold standard, we reviewed 130 consecutive bone marrow cores obtained from 114 AIDS patients along with results of concurrent blood and/or bone marrow aspirate cultures to determine the usefulness of histologic examination for diagnosis of mycobacterial and fungal infections. We also compared the ability of Ziehl-Neelsen, auramine-rhodamine (AR), polyclonal antibody to Mycobacterium bovis (Ab), and Gomori's methenamine silver staining to detect infections. Twenty-seven patients had mycobacterial infection (25 Mycobacterium avium-intracellulare complex cases and two Mycobacterium tuberculosis cases) detected by blood and/or bone marrow cultures. The maximum sensitivity of histology was 50% when the auramine-rhodamine stain and the polyclonal antibody to M bovis were used in combination. The single best stain was auramine-rhodamine, with a sensitivity of 44%, followed by the polyclonal antibody to M bovis (35%). Granulomas were observed in nine cases of mycobacterial infection and did not correlate with the presence of stainable organisms. Of seven patients with positive fungal cultures of bone marrow, four had granulomas and a positive Gomori's methenamine silver stain, one had only a positive stain, and two had neither granulomas nor a diagnostic stain. Overall, granulomas were not sensitive for the detection of infections when culture-proven mycobacterial and fungal cases were evaluated together. We conclude that bone marrow examination has a limited value in the routine evaluation of common opportunistic infections in AIDS patients and recommend that less-invasive tests, such as blood cultures, be obtained initially in most circumstances.

Hodgkin's and non-Hodgkin's lymphoma: spectrum of morphologic and immunophenotypic overlap

Immunoperoxidase markers are useful and often essential in distinguishing among lymphocyte-predominant Hodgkin's lymphoma, T-cell-rich B-cell lymphoma, and lymphocyte-rich classic Hodgkin's lymphoma. However, it is becoming increasingly clear that these "entities" are closely related clonal B-lineage neoplasms that may intertransform and/or coexist. We hypothesized that, just as there are cases with morphologic overlap, there would also be immunophenotypic overlap that would be found when a series of such cases is studied in detail. Eight cases of lymphocyte predominant Hodgkin's lymphoma, eight cases of lymphocyte-rich classic Hodgkin's lymphoma, seven cases of T-cell-rich B-cell lymphoma, and four cases of large B-cell lymphoma with focal features of T-cell-rich B-cell lymphoma were examined by the immunoperoxidase technique for expression of CD3, CD15, CD30, CD20, CD57, epithelial membrane antigen, and Epstein-Barr virus latent membrane protein (EBV LMP). All eight of the lymphocyte-predominant Hodgkin's lymphoma cases had CD20+ lymphocytic and histiocytic cells and CD57+ rosettes; however, in two cases, occasional lymphocytic and histiocytic cells were also weakly positive for CD15, CD30, and EBV LMP. Among the eight lymphocyte-rich classic Hodgkin's lymphoma cases, CD15+ Reed-Sternberg (R-S) cells were found in seven; however, in three of these cases rare rosettes of CD57+ cells surrounded the R-S or lacunar cells. In one case of large B-cell lymphoma the malignant cells resembled R-S cells and were CD20+, EBV LMP+, CD30+, CD15-, and surrounded by rosettes of CD57+ T cells. The majority of the cases exhibited the "expected" immunophenotypic patterns; however, the exceptional cases that were found serve to confirm the interrelationship among these clonal B-lineage neoplasms.

An unusual etiology of biliary hilar obstruction and the potential role of acidic fibroblast growth factor in the development of a biliary neuroma

Neuroma of the biliary tract is a rare condition thought to be caused by trauma secondary to cholecystectomy. More rare is the occurrence that causes symptomatic biliary obstruction. A 65-year-old woman was hospitalized because of abdominal pain, nausea, vomiting, and general malaise of 1 to 2 months duration. Cholecystectomy had been performed 40 years before. Ultrasound revealed hepatomegaly and dilated intrahepatic ducts. CT showed intra- and extrahepatic ductal dilatation with questionable intraductal mass. Endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography demonstrated stricture of the hepatic duct bifurcation. The biliary bifurcation was resected, and hepaticojejunostomy was performed. The patient's postoperative course was unremarkable. Histological examination of the surgical specimen revealed positive staining for the S-100 antigen of the obstructing luminal stricture (without evidence of cholangiocarcinoma), which was consistent with a biliary neuroma. Positive staining was also found for acidic (and not basic) fibroblast growth factor (FGF) and two of its high affinity receptors (FGFR-1 and FGFR-4). This study supports the apparent association between biliary neuromas and cholecystectomy as well as the potential role of an established angiogenic and neurogenic growth factor in the formation of this tumor. Finally, this case is also unique in that it represents the longest interval between cholecystectomy and presentation of a biliary neuroma, 40 years after surgery.

Duplication and dilaceration of a crown with hypercementosis of the root following trauma: a case report

Trauma to a primary mandibular central incisor resulted in a rare case of dilaceration and duplication of crown with hypercementosis of the root in the permanent successor. This tooth was extracted. This article highlights the consequences of trauma to a primary tooth for a developing permanent successor.

A comparative study of retentive strengths of zinc phosphate, polycarboxylate and glass ionomer cements with stainless steel crowns--an in vitro study

This study was conducted on 30 extracted human primary molars to assess the retentive strengths of zinc phosphate, polycarboxylate and glass ionomer cements. The teeth were embedded in resin blocks and were randomly divided into 3 groups of 10 each. The occlusal surfaces of all teeth were reduced uniformly by 1.0 to 1.5 mm. All mesial, distal undercuts were removed and sharp angles rounded. This was followed by cementing pretrimmed and precontoured stainless steel crowns on each tooth with hand pressure and storing in artificial saliva at 37 degrees C for 24 hours. Retentive strength was tested using Instron Universal Testing Machine. The load was applied starting from a zero reading and gradually increased until the cemented stainless steel crowns showed signs of movement and then the readings were recorded. It was found that retentive strengths of zinc phosphate and glass ionomer cements were statistically better (P < 0.05) when compared to the polycarboxylate cement. Negligible difference (0. 59 kg/cm2) was however observed between zinc phosphate and glass ionomer cements.

A dermatoglyphic predictive and comparative study of Class I, Class II, div. 1, div.2 and Class III malocclusions

A study was conducted using dermatoglyphics to predict and compare Class I, Class II, div. 1, div.2 and Class III malocclusions. A total of 96 subjects were divided into 3 malocclusion groups, i.e. Class I (control group), Class II, div.1, div.2 and Class III (experimental group) in the ages of 12-14 years. The dermatoglyphic findings revealed that the craniofacial Class II, div. 1, div.2 pattern was associated with increased frequency of arches and ulnar loops and decreased frequency of whorls, whereas in Class III, there was an increased frequency of arches and radial loops with decreased frequency of ulnar loops. In predicting Class III malocclusion, based on frequency of arches, the sensitivity values were found to be higher and more reliable than the sensitivity values of Class II, div.1 and div.2 malocclusion.

Childhood thrombocytopenic purpura--review and a case report

Childhood idiopathic thrombocytopenic purpura is a rare condition seen in children. A case of a 10 year old female child is reported. Bleeding from the gingiva and petechiae on the tongue were observed. The blood picture was normocytic normochromic with neutrophilia and thrombocytopenia. Bone marrow study was suggestive of marrow changes in idiopathic thrombocytopenic purpura. Dental extractions were postponed. Recognition of the disease by the dental profession is stressed.

Pulmonary infiltrates following administration of paclitaxel

The clinical spectrum of hypersensitivity reactions reported with paclitaxel has not included the occurrence of pulmonary infiltrates. This report describes three patients who developed transient pulmonary infiltrates after receiving paclitaxel. These infiltrates were noted 2 days to 2 weeks after administration of paclitaxel. The infiltrates resolved spontaneously in all the patients but one of them did receive steroid therapy. This syndrome of transient pulmonary infiltrates did not reoccur in the two patients who were rechallenged with paclitaxel. Physicians should be made aware of this unique occurrence during the course of treatment with paclitaxel.

Clinical and radiological evaluation of zinc oxide-eugenol and Maisto's paste as obturating materials in infected primary teeth--nine months study

The present study, performed in-vivo, included 30 infected primary teeth in 26 children in the age group of 3-8 years. The purpose of this study was to compare the efficacy of two obturating materials, zinc oxide-eugenol and Maisto's paste, in infected primary teeth. 30 teeth were divided into two groups of 15 teeth. Teeth in Group I were obturated using zinc oxide-eugenol and those in Group II were obturated using Maisto's paste. On clinical evaluation, teeth obturated with Maisto's paste showed 100% success. Five teeth that were overfilled with Maisto's paste showed complete resorption of excess material within 3 months while the two teeth overfilled with zinc oxide-eugenol showed incomplete resorption of the excess material even after 9 months. Zinc oxide-eugenol treated cases showed only 26.7% bone regeneration while in case of Maisto's paste, it was 93%. Complete healing of the inter-radicular pathology was seen with Maisto's paste. However, the pathology was present in 40% of the zinc oxide-eugenol treated teeth even after 9 months. Maisto's paste was thus seen to be superior to zinc oxide-eugenol both in clinical as well as radiological evaluation, done over a period of 9 months in relation to bone regeneration, healing of inter-radicular pathology and resorption of excess material.

Configuration of root canals in permanent mandibular first molars--an in vitro study

The study attempts to show a number of variations in the root canal morphology of permanent mandibular first molar. The presence of variations increases the chance of failure of endodontic treatment. Knowledge about internal anatomy of the teeth is very essential for a favourable prognosis.

An in vitro comparative evaluation of the tensile bond strength at the two interfaces of the sandwich technique

This study was conducted to compare the tensile bond strength at the two interfaces of the "sandwich technique". 48 hours after the specimens were tested, using Hounsfield tensometer. Load was gradually applied on to the specimen till the bond at the interface failed. The load at which the bond failed was recorded and analysed for statistical significance. From the present study it can be concluded that the bond between glass ionomer and dentine is better than the bond between glass ionomer and composite resin.

Cerebral vasculitis complicating rheumatoid arthritis

Central nervous system vasculitis is a rarely described complication of rheumatoid arthritis. We report a case of cerebral vasculitis in a 55-year-old woman with a 7-year history of seropositive, nodular rheumatoid arthritis. Striking multifocal abnormalities of the white matter on magnetic resonance imaging led to a suspicion of vasculitis despite lack of clinical evidence of extracranial vasculitis and normal findings on cerebrospinal fluid studies and cerebral angiography. After institution of treatment with glucocorticoids and azathioprine, she survived in stable condition for 14 months from the onset of symptoms. Postmortem examination of the brain revealed vasculitis and chronic ischemic changes.

A comparison of bitewing radiography and fibreoptic illumination as adjuncts to the clinical identification of approximal caries in primary and permanent molars

A clinical study was conducted on 150 approximal surfaces which were positive for caries by fibreoptic transillumination (FOTI), and these approximal surfaces were examined with bitewing radiography. Of these 54.7% and 41.3% were diagnosable through bitewing radiography and clinical examination respectively. And it was clearly understood that FOTI was a reliable method in detecting approximal carious lesions.

Evaluation of 2% sodium fluoride iontophoresis as an alternative to lining in Class I cavity preparations--an in vivo study

The study carried out on 110 permanent teeth in 44 randomly selected patients with age ranging from 8-14 years, to evaluate the efficacy of 2% sodium fluoride iontophoresis as an alternative to cavity lining in Class I preparations. 65 teeth were included in the experimental group (2% sodium fluoride iontophoresis) and 4 teeth in the control group (Zinc phosphate linings). Sensitivity gradings were done on a subjective discomfort scale. From the results, it was found that after cavity preparation, all the teeth (100%) were sensitive to air blast, water jet and probing in varying severity. But after iontophoresis and amalgam restoration the sensitivity reduced to 4.6%. Six months and nine months follow up revealed that all the teeth were vital and asymptomatic.

Stereotaxic core breast biopsy: value in providing tissue for flow cytometric analysis

OBJECTIVE

Stereotaxic core biopsy provides intact samples of breast tissue for accurate histologic analysis. We conducted a study to determine if prognostic data could also be successfully derived from such core samples and how the data correlate with surgical biopsy.

MATERIALS AND METHODS

Both core and surgical breast biopsies from 135 patients were processed under a uniform flow cytometry protocol. Samples were coded and then randomly processed at an outside flow cytometer and interpreted by an independent pathologist; the code was broken and patients' results correlated only after all samples were completely analyzed.

RESULTS

Core breast biopsy provides intact tissue that can be successfully processed by a flow cytometer, even after being embedded in paraffin for initial histologic analysis. Larger cores (14 gauge) had fewer insufficient samples, as recorded on ploidy histograms. Although ploidy may reflect the underlying aggressiveness of a lesion and assist in evaluating breast cancer, surgical-pathologic correlation with stereotaxic biopsy indicated, as has been confirmed in other studies, considerable overlap of different ploidy types between benign and malignant conditions. There was no correlation between mammographic presentation and ploidy or S-phase fractions.

CONCLUSION

Stereotaxic large-core biopsy can enable accurate histologic diagnosis of breast disease and furnish sufficient tissue for flow cytometric measurements of ploidy and S-phase fractions, even at an interval following paraffinization. Such prognostic information aids in planning of adjuvant therapy, allows flexibility should surgery fail to provide enough tissue for DNA study, and helps radiologists further market stereotaxic biopsy to clinicians.

An evaluation of pH changes of human dental plaque after oral rinsing of commonly prescribed syrup medications

The study was carried out on 60 school going children (dft/DMFT 2-5) aged 8-13 years randomly distributed into six age groups of ten subjects each. One group acted as a control in which subjects rinsed with 10% sucrose while in the other five groups, the subjects rinsed with 5 commonly prescribed syrup medications for 10 seconds. Plaque samples were collected before rinsing and at 5,10,20,30 min. intervals post rinsing and plaque pH was measured extraorally. All the 5 groups showed drop in the plaque pH, similar to control group 10% sucrose solution, but not to the extent of critical pH (5.5).

In vitro evaluation of micromarginal leakage of three filling systems--an autoradiographic analysis using radio isotope S35 as a tracer

An in vitro study was carried out on 60 human pre- molar teeth to study the sealing efficacy of Glass Ionomer, Silver amalgam, Composite resin and cavity varnish in Class V cavities. The filled specimens were thermocycled (4 degrees C +/- 2 degrees C and 60 degrees C +/- 2 degrees C) and subjected to Radio Isotope penetration tests. S35 was used as a tracer and autoradiography for detecting the microleakage. The extent of penetration of S35 in case of each material was assessed. No material was found to completely seal the cavity, however, Glass Ionomer could minimise the microleakage. Amalgam restorations exhibited gross microleakage which reduced to a great extent after application of cavity varnish. Composite resin was found to be superior to Silver amalgam in controlling microleakage.

Prevalence location and patency of accessory canals in primary molars using dye penetration under vacuum suction technique--an in vitro study

A study conducted on 120 primary molars (30 each of maxillary and mandibular 1st and 2nd molars) to find out the prevalence, location and patency of accessory canals and furcation formina using safranin red dye revealed the presence of accessory canals in 46 teeth (38.33 percent) with the major site being the furcation and furcation region.

Pleural effusion in patients with systemic cholesterol embolization

We evaluated two patients with systemic cholesterol embolization (SCE) associated with the development of pleural effusions. These two patients had evidence of atherosclerosis and presented with livedo reticularis, renal insufficiency, and gangrenous cutaneous changes as manifestations of their SCE. In both cases, closed pleural biopsies demonstrated acute inflammation of the parietal pleura. Our experience with these individuals and a review of the medical literature suggest that pleural injury from atheromatous embolization may occur. Physicians caring for patients with SCE should be aware of the possible association of pleural reactions with this process.

In vitro evaluation of NaF and APF-gel application on surface microhardness of enamel in children of low, optimum and high fluoride areas

An in vitro study was conducted on 78 sound human pre-molars collected from low (0.24 ppmF), optimum (0.7 ppmF) and known endemic fluoride areas (> 1.5 ppmF), to study the effects of topical application of sodium fluoride and APF-gel on surface microhardness of enamel of these three areas using Vickers microhardness measurements before and after application of topical fluorides at time intervals of 1/2 an hour, 6 hours and 24 hours. It was found that both the topical fluorides increased the surface microhardness of enamel in the three areas; the maximum increase in surface microhardness was observed in fluorosed teeth. APF-gel was found to be more effective than sodium fluoride.

Hydroxylation of pentamidine by rat liver microsomes

The antiprotozoal/antifungal drug pentamidine [1,5-bis(4-amidinophenoxy)pentane] has been recently shown to be metabolized by rat liver fractions to at least six putative metabolites as detected by high-performance liquid chromatography. Two minor metabolites have been previously identified as N-hydroxypentamidine and N,N'-dihydroxypentamidine. In this study, the two major microsomal metabolites have been identified as the 2-pentanol and 3-pentanol analogs of pentamidine [1,5-di(4-amidinophenoxy)-2-pentanol; and 1,5-bis(4-amidinophenoxy)-3-pentanol]. As well, a seventh putative metabolite has been discovered and identified as para-hydroxybenzamidine, a fragment of the original drug. Whereas the cytochromes P-450 have been demonstrated as the enzyme system responsible for pentamidine metabolism, hydroxylation of the drug was not inducible by phenobarbital, beta-naphthoflavone, clofibrate, isosafrole, pregnenolone-16 alpha-carbonitrile, ethanol or pentamidine pretreatment of rats. The kinetics of the production of the two major microsomal metabolites has been determined as Km = 56 +/- 19 microM and Vmax = 126 +/- 21 pmol/min/mg microsomal protein for the 2-pentanol analog, and Km = 28 +/- 0.28 microM and Vmax = 195 +/- 2.4 pmol/min/mg microsomal protein for the 3-pentanol analog. Therefore, the mixed-function oxidases readily convert pentamidine to hydroxylated metabolites, but exactly which isozyme(s) of cytochrome P-450 is responsible is not clear.

Efficacy of automated biopsy guns versus conventional biopsy needles in the pygmy pig

Debate over which biopsy needle is the best has intensified recently with the introduction of automated biopsy guns including the 18-gauge long-throw and short-throw Biopty, the 18-gauge Cook, and the 14- and 18-gauge Klear Kut. To evaluate the efficacy of these mechanized biopsy guns versus that of conventional manual biopsy needles in the acquisition of adequate tissue for histopathologic evaluation, open hepatic and renal biopsies were performed in 15 pygmy pigs. The specimens were evaluated separately in a double-blind fashion by two histopathologists using graded criteria. Overall, the best results were obtained with the manual 14-gauge Tru-Cut needle, the long-throw 18-gauge Biopty gun, and the 18-gauge Cook biopsy gun. By comparison, the aspiration-type needles did not perform as well when considered as a group. Several other needles scored well in the biopsy of either the liver or kidney, but not in both. Disappointing results were obtained with the Klear Kut guns (both 14- and 18-gauge) and the Vacu Cut and PercuCut needles.

Novel pentamidine analogs in the treatment of experimental Pneumocystis carinii pneumonia

We have recently demonstrated that substitution of imidazoline moieties for the amidine groups of pentamidine produces a molecule that is effective against rat Pneumocystis carinii pneumonia and that is apparently less toxic than pentamidine. For this reason, 10 novel imidazoline substituted compounds were evaluated for their effect against rat P. carinii pneumonia. While several of the new compounds were observed to have advantages over pentamidine in the treatment of disease in the rat model, only one compound stood out as a potential new clinical agent. Treatment for 2 weeks with intravenous (i.v.) doses of 1,3-di(4-imidazolino-2-methoxyphenoxy)propane (DIMP) at 1 mg/kg per day produced an anti-P. carinii pneumonia effect equivalent to i.v. doses of pentamidine at 10 mg/kg per day. Although pentamidine and one of the test drugs, 1,3-di(4-imidazolinophenoxy)propane, showed no activity against P. carinii pneumonia when administered per os, DIMP exhibited potent anti-P. carinii pneumonia activity when given by daily gavage doses of 40 and 25 mg/kg. DIMP retained significant activity when given every other day by a gavage dose of 25 mg/kg. No toxicity was observed with the drug at any of the dose levels or by either of the routes of administration. However, the low solubility of the drug prevented testing at higher i.v. doses. Our conclusion is that DIMP has the potential of providing a safer and more effective alternative to pentamidine for the treatment of P. carinii pneumonia.

Application of analytical standards in method development: selected chlorinated phenols and herbicides

Pure analytical standards are key components in the successful development of accurate analytical methods. When such compounds are unavailable commercially, a laboratory synthesis activity can provide such materials for use in method development. An example of such an approach is the synthesis of ethyl ethers of chlorinated phenols and ethyl esters of several phenoxy herbicides. Individual synthesis steps and the characterization of such materials are described. The use of such analytical standards in method development is vital for defining method characteristics. In addition, such materials are helpful in diagnosing chromatographic and mass spectral problems in the course of this work. Key mass spectral information including parent and daughter scans obtained from these analytical standards by using tandem mass spectrometry provide the basis for a new analytical method with increased sensitivity and specificity.

Effect of umbilical vein oxytocin on puerperal blood loss and length of the third stage of labor

The use of umbilical vein injection of oxytocin was compared with traditional management of the third stage of labor. Pregnant women were randomized to receive intravenous oxytocin after the delivery of the placenta (n = 25) or oxytocin via the umbilical vein immediately after cord clamping (n = 25). Those who received umbilical vein oxytocin had a shorter third stage of labor (4.1 versus 9.4 minutes), less measured blood loss (135 versus 373 ml), and a lower drop in hematocrit (3.9% versus 6.2%). Intraumbilical vein oxytocin appears to be a useful alternative to traditional management of the third stage of labor.

Neutrophilic eccrine hidradenitis associated with induction chemotherapy

We report three new cases of neutrophilic eccrine hidradenitis associated with induction chemotherapy which resolves two major points. First, because two of our patients had testicular carcinoma; this firmly establishes that NEH is not exclusively seen in patients with acute myelogenous leukemia or Hodgkin's lymphoma as previously reported. Second, because two of our patients did not receive cytarabine which has previously been suspected of being the causative agent, it is apparent that this disorder may be produced by more than one chemotherapeutic agent or combination of agents. The histologic features with a discussion of the spectrum of changes which may be seen are presented.

Effects of catechol estrogen methyl ethers on lipid metabolism in prepubertal rats

Thirty-five day old ovariectomised rats were given daily subcutaneous injections (0.05-5.0 micrograms/100 gm body weight) of estradiol (E2) 2-methoxyestradiol (2-ME2) or 4-methoxyestradiol (4-ME2) for six days. At the end of the last injection, the animals were sacrificed and serum lipoproteins were analysed. It was observed that cholesterol decreased significantly in normal fed animals who received E2 and 4-ME2, while no effect was seen in cholesterol fed animals. In the E2 treated group there was a decrease in esterified and free cholesterol, while in the 4-ME2 group only esterified cholesterol decreased. High density lipoproteins were significantly elevated in the E2 treated group. However, there was an increase in very low density lipoproteins and a decrease in low density lipoproteins in 2-ME2 and 4-ME2 treated groups. These results suggest that catechol estrogens may play an important role in the lipoprotein metabolism and atherosclerotic diseases, and the mechanism of action may differ from that of estradiol.

Chronic myelomonocytic leukemia: value of touch preps

(CMML) Chronic myelomonocytic leukemia is not an uncommon leukemia occurring in elderly individuals. Cutaneous manifestations are unusual and portend a poorer prognosis. Touch imprints from a skin punch biopsy may help to quickly confirm clinical suspicions of an underlying leukemia or lymphoma.